■ Recommendations call for cutting back consecutive hours without sleep and providing more off days.

Five years ago, the Accreditation Council for Graduate Medical Education implemented an 80-hour-workweek limit for residents -- an effort to ease resident fatigue and boost patient safety. But a new Institute of Medicine report says residents are still too tired.

The 324-page report, released in December, calls for keeping the 80-hour standard but recommends changes such as limiting shifts with no sleep period to 16 hours, increasing time off per month and restricting moonlighting hours. The IOM recommendations also include increasing supervision by experienced physicians, limiting patient loads, scheduling overlaps to make handoffs more seamless and providing transportation home for fatigued residents.

"Our overarching conclusion is that the science clearly shows that fatigue increases the chances for errors, and residents often work long hours without rest and regular time off," said Michael M.E. Johns, MD, the report's chair and chancellor of Emory University in Atlanta.

The report estimates it will cost $1.7 billion a year to pay for the recommendations, which will require added work for attending physicians, plus hiring more residents and other health care staffers. It also says stakeholders in residency funding should share the cost.

The American Medical Association supports keeping the 80-hour limit and spreading the costs of changes among payers. "The AMA is deeply concerned about working conditions for resident physicians and the role that resident fatigue may play in both patient safety and the welfare of physicians in training," AMA Board of Trustees member Samantha L. Rosman, MD, said in a statement.

The Assn. of American Medical Colleges said duty hours ought to be examined, but it stopped short of agreeing that shifts need to be cut. The American Assn. of Neurological Surgeons was more critical, saying further restrictions in duty hours "will jeopardize quality resident training and patient safety."

The ACGME will host a March 2009 conference with international leaders in graduate medical education to review the IOM report and discuss potential changes to duty-hour standards.

Requiring sleep breaks

Under the IOM recommendations, residents would still be able to log 30-hour shifts, but after working 16 hours they would be required to get five hours of uninterrupted sleep between 10 p.m. and 8 a.m. They then could return to work for educational or transitional activities but not admit new patients.

The report noted that duty-hour limits frequently are violated and underreported. In 2006-2007, the ACGME found that 8.8% of residency programs were "substantially noncompliant with some aspect of duty-hour limits," according to the committee of medical and scientific experts who wrote the report.

Committee members also said that was likely an "underestimation of noncompliance" due to the risk of disaccreditation for training programs that report all violations. They called for increased policing by the ACGME, Joint Commission and Centers for Medicare & Medicaid Services.

"What they're asking for is tighter oversight," said ACGME CEO Thomas J. Nasca, MD. "We have evolved from a situation five years ago where there was absolutely no oversight."

As the report stirs debate in the medical community, one major concern voiced by residents and program directors is how to balance rest with hands-on experience.

"You hear the horror stories from people who've come before you," said Amy Schindler, MD, a third-year internal medicine resident at Vanderbilt Medical Center in Tennessee. "I'm glad to not be practicing under those conditions. But those people are now the great doctors that we're learning from."

One doctor who logged staggering hours as a resident prior to the 2003 work-hour standards is H. Hunt Batjer, MD, professor and chair of neurological surgery at Northwestern University Feinberg School of Medicine in Chicago. He said unrestricted hours in the past weren't good for residents or patients, but he also has doubts about the IOM report's claim that tired residents increase errors.

"I would say that you've got some subtle, not very scientific evidence that after being awake for a long period of time you're not as precise with some of your hand-eye coordination and some of your attention skills as when you are fresh," said Dr. Batjer, who testified before the IOM committee and oversees neurological surgery residents. "Now, does that translate into medical errors? The evidence of that is very, very flimsy, if present at all."

Another area of concern is the patient handoff portion of shifts.

The IOM recommendations could create more handoffs due to the mandated five-hour sleep period on 30-hour shifts. The report says most errors occur during handoffs and additional training to improve transitions is essential to patient safety.

A 2007 study in the Archives of Internal Medicine found that 87% of surveyed faculty said continuity of care declined after duty-hour limits were imposed. The study also said that while residents' well-being improved, faculty workloads increased and their job satisfaction decreased.

At Vanderbilt University School of Medicine, residents have been reluctant to accept some handoff practices, said John Sergent, MD, vice chair for education and the residency program director in the Dept. of Medicine.

He said Vanderbilt put in "night float" shifts for internal medicine residents to cover the work-hour limits implemented in 2003. Night floats are residents who relieve regular teams for eight to 12 hours then hand patients back to daytime teams.

But Vanderbilt's internal medicine residents disliked using night floats because of the increased handoffs and lobbied successfully to remove them in 2004. The practice may return if the IOM recommendations are embraced.

"If we go to this new policy, we will have to have some sort of float system," Dr. Sergent said. "It would definitely change the way we do things. What we have now is working well. Our residents love it. They didn't want to be at a place with a lot of night floats and handoffs."

ADDITIONAL INFORMATION

Resident work hours

In 2003, the Accreditation Council for Graduate Medical Education set duty hour standards to address resident fatigue. A December Institute of Medicine report concluded that residents still are tired. Here is a look at the ACGME standards and IOM recommendations:

2003 ACGME duty hour limits

IOM recommendation

Maximum work hours per week

80 hours, averaged over 4 weeks

No change

Maximum shift length

30 hours (admitting patients up to 24 hours, then 6 more hours for transitional and educational activities)

30 hours (admitting patients up to 16 hours, plus 5-hour sleep period between 10 p.m. and 8 a.m. with remaining hours for transition and educational activities; 16 hours with no protected sleep period

Minimum time off between scheduled shifts

10 hours after shift length

10 hours after day shift; 12 hours after night shift; 14 hours after any extended duty period of 30 hours and no return until 6 a.m. of next day

Mandatory time off duty

4 days off per month; 1 day (24 hours) off per week, averaged over 4 weeks

5 days off per month; 1 day off per week, no averaging; one 48-hour period off per month